The Etiology of Depression According to Traditional Chinese Medicine

OVERVIEW

Traditionally, psychiatric disease in Chinese Medicine is described by a single inclusive phrase of ‘mania and withdrawal’ (dian kuang). Mania denotes a state of excitement characterized by noisy, unruly, and possibly aggressive behavior (Wiseman & Feng 1998); it is due to hyperactivity of yang qi from any cause: heat that arises from qi stagnation, vacuity heat due to yin vacuity, fire transformation, etc. Withdrawal refers to emotional depression, indifference, no desire to eat or drink; it is a yin pattern in which yang is either not present because of qi or yang vacuity, or it is not flowing freely due to binding of depressed qi and phlegm (Wiseman & Feng 1998). Although classically the terms mania and withdrawal refer to severe forms of mental derangement, this classification is still valid in the treatment of unipolar depressive episodes even when not complicated by comorbidity or psychotic features.

DISEASE CAUSES AND MECHANISMS IN DEPRESSION

There are four concepts in Chinese Medicine that are extremely useful in understanding the progression of depression patterns, in differentiating conflicting signs and symptoms encountered in people experiencing depression, and in evaluating and treating complex pattern combinations. These four concepts are:

1. The concept of qi stagnation, its ramifications and complications

  1. 2.    Zhu Dan-xi’s theory of the six depressions
  2. 3.    Liu Wan-su’s theory of similar transformation
  3. Li Dong-yuan’s yin fire theory.

We were first introduced to these concepts through the teachings of Bob Flaws, especially as they applied to the treatment of gynecological and difficult-to-treat disorders. As we continued refining the treatment protocol for depression outlined in this manual, it became clear that these theories were fundamental in understanding the complex symptom pictures presented by our depressed patients. What follows is by no means a comprehensive description of these theories, but rather an overview of their relevance in the treatment of depression. For a more complete explanation of the theories presented below, please refer to the numerous writings of Bob Flaws cited in the bibliography. We will begin by explaining the six depressions and the theory of similar transformation, as these two theories help explain the progression of patterns that emerge from qi stagnation. We will describe then, in some detail, the mechanisms underlying qi stagnation patterns, and finally we will introduce the theory of yin fire.

The Six Depressions or Six Stagnations

The six depressions involve stagnation of either qi, blood, dampness, phlegm, food, or fire. Qi stagnation underlies all the others because qi is responsible for the movement and transformation of blood, dampness, phlegm, and food, and also because stagnant qi, being yang in nature, may eventually turn into fire or heat. Blood, damp-ness, phlegm, and food are all yin substances; if the qi becomes stagnant and depressed, it may result in any of these four not being moved or transformed properly, and they may accumulate (Flaws 1997). At the same time, the accumulation of any of these four yin substances may obstruct the free flow of yang qi, further complicating qi stagnation; the theory of similar transformation described below will help us to understand fire stagnation. Each one of the six stagnations is identifiable by specific signs and symptoms (Wiseman & Feng 1998).

The Theory of Similar Transformation

According to Liu Wan-su, a great master of internal medicine from the Jin-Yuan dynasties, the host or ruling qi of the organism is yang in nature, and therefore warm. As explained by Flaws, physiologically this means that ‘any evil qi accumulating in the body, whether externally invading or internally engendered will tend to become warm over time because the basic host or ruling qi of the body is hot’ (Flaws 1997, p. 52). For this reason, even if a disease was initially caused by cold, or is originally yin in nature, there is a tendency for this disease to transform into a hot pathology if the host yang qi is sufficiently strong (Flaws 1997).

When qi becomes stagnant and depressed, it backs up and accumulates, and may transform into pathological heat or fire because qi is yang in nature. Even though the other four depressions — blood, dampness, phlegm, and food — are originally yin, they obstruct the free flow of qi. The qi tends to become stuck behind or entangled with these yin accumulations, and these four yin depressions also tend to become hot stagnations: dampness tends to become damp heat, stagnant food tends to become complicated by heat, phlegm tends to transform into phlegm heat (or fire), and static blood can become heat stasis (Flaws 1997). In the subsequent sections detail-ing the evolution of depression patterns, the clinical relevance of the six stagnations, especially qi stagnation, heat transformation, and dampness accumulation, will become clear.

Liver Qi Stagnation: Ramifications and Complications

As explained previously, the liver plays a pivotal role in the precipitation of depressive episodes. When confronted by continuous and pro-longed psychosocial or emotional stress, the liver’s function of spreading the qi is impaired; the liver cannot maintain its free and unobstructed flow and the qi stagnates. The term ‘liver depression qi stagnation’ usually refers to qi stagnation due to affect damage (damage by the emotions), while qi stagnation alone may be due to other causes (Wiseman & Feng 1998). When the qi becomes stagnant due to liver depression, one or more of the following mechanisms are set in motion. Stagnant qi may:

n accumulate along the pathway of the liver channel and its paired channel the gall bladder

n transform into heat

n counterflow sideways or upwards

n result in blood stasis

n result in dampness and phlegm accumulation.

Accumulation

When the qi backs up and accumulates, it may create fullness and dis-tension in the areas traversed by the channels and vessels associated with the liver. The liver channel is connected with the anterior aspect of the legs and thighs, the pelvic region, the abdominal area, the rib cage, the chest, the throat, gums, eyes, and vertex of the head. The clinical symptoms of qi accumulation are oppression in the chest, belching, rib cage, and abdominal distension; additionally, distending pain and the intermittent appearance of a lump are sometimes observed. In addition, functional changes associated with the accumulation of qi along these areas include painful menstrual periods, digestive disturbance, difficulty in breathing, and a feeling of constriction in the throat. The liver connects with the pericardium channel which traverses the anterior aspect of the arms, the upper abdomen, and chest. In fact, the liver and pericardium are considered to be an extension that links the upper and lower regions of the body. The liver and pericardium are known as the foot jueyin and arm jueyin channels respectively.

HeatTransformation

As mentioned above, qi is yang and therefore, when it accumulates and stagnates, it tends to become hot, and eventually transforms into pathological heat or fire. Because heat is yang in nature and tends to move upwards, this pathological heat may affect the function of those viscera and bowels that are considered to be above the liver, such as the stomach, heart, and lungs. Alternatively it may manifest in the upper parts of the body, such as the mouth, nose, ears, eyes, and head. Because the shen, or spirit, resides in the heart, heat due to liver depression may cause the spirit to be agitated or restless. Heat resulting from liver depression qi stagnation is known as depressive or transformative heat.

Counterflow

The term qi counterflow means a reversal of the normal movement of qi (Wiseman & Feng 1998); it usually implies the venting of excessive liver qi to the areas of the body where it should not be (Schnyer & Flaws 1998). It is said in Chinese Medicine that anger, which is the corresponding emotion for the liver, makes the qi rise. The liver has an interior—exterior (yin—yang) connection with the gall bladder channel, which traverses the lateral aspect of the legs, the sides of the pelvis, the sides of the chest, the sides of the neck, and the temporal aspect of the head. The surplus of qi generated by accumulation of liver qi will tend to move into the gall bladder channel, and may precipitate neck and shoulder tightness and one-sided headaches.

When liver qi counterflows upwards there may be dizziness, headaches, red facial complexion, tinnitus, pain and fullness in the chest and the rib side. If the stomach is affected, there may be belch-ing, burping, acid regurgitation, nausea and vomiting. If it affects the lungs, there may be coughing and wheezing; if the heart is affected there may be insomnia, irritability, and restlessness. If liver qi counterflows horizontally, it may affect the spleen and cause lack of appetite, abdominal distension, and diarrhea.

Accumulation, heat transformation, and counterflow are part of a continuum that is not always so clearly delineated in clinical practice.

Blood Stasis

In addition to regulating the smooth flow of qi (coursing and dis-charge), the liver stores the blood. In Chinese Medicine it is said that the qi moves the blood and the blood nourishes the qi. When qi fails to move the blood, qi stagnation may cause, and be further exacerbated by, blood stasis (Wiseman & Feng 1998). Long-term or severe qi stagnation may result in blood stasis, and blood stasis due to any other cause may in turn aggravate qi stagnation (Schnyer & Flaws 1998). The simultaneous occurrence of qi stagnation and blood stasis is commonly encountered in clinical practice; it generally involves concomitant symptoms of qi stagnation, such as abdominal distension, and chest oppression with symptoms of blood stasis, such as menstrual pain and clots in the menstruate.

Blood is needed to moisten the liver in order for it to perform smoothly its functions of coursing and discharge. Blood vacuity and, by extension, yin vacuity can create or exacerbate both qi stagnation and blood stasis.

Dampness and Phlegm Accumulation

The qi moves and transforms the body fluids; therefore, prolonged qi stagnation may result in dampness accumulation, and dampness may lead to phlegm. Phlegm can then lodge in the viscera and bowels, the channels and network vessels, or in the body’s orifices, further exacerbating the obstruction of qi and affecting the functions of those viscera, channels, and orifices (Schnyer & Flaws 1998). Dampness accumulation and phlegm obstruction arising for any other reason may also precipitate and exacerbate liver qi stagnation.

Yin Fire

Yin fire is a complex theory developed by another great master of internal medicine, Li Dong-yuan, who is known as founder of the school of thought known as Supplementing Earth (spleen) and author of the Pi Wei Lun (Treatise of the Spleen and Stomach). Yin fire refers to heat that stems from the spleen and that is associated with damp-ness; it is heat that arises from the yin or lower part of the body. It is a type of pathological (yin) heat versus the healthy (yang) heat. Yin fire (yin huo) should not be confused with vacuity heat (xu re); vacuity heat is a type of yin fire, but yin fire is a larger and more complex category which includes vacuity heat (Flaws 1997). Vacuity heat is due to insufficiency of yin; yin fire is due, in part, to an accumulation of a yin substance which has transformed into heat.

There are five basic mechanisms associated with the production of yin fire: spleen vacuity, damp heat, liver stagnation, blood (yin) vacuity, stirring of ministerial fire. These five mechanisms are inter-dependent, and they mutually engender and promote one another (Flaws 1997).

Spleen Vacuity

Spleen vacuity is considered the root of yin fire. If the spleen becomes vacuous and weak, and loses its ability to control the movement and transformation of body fluids, these fluids tend to gather and accumulate, eventually transforming into dampness.

Damp Heat

The dampness generated by spleen vacuity will tend to pour down-wards; dampness accumulation over a long period of time may eventually become damp heat. Even though this damp heat is located in the lower burner,’ the heat moves upwards, further disturbing the spleen and damaging the heart and lungs above.

Liver Stagnation

As mentioned above, the liver and spleen have a very close relationship via the control cycle of the five phases. Spleen vacuity may cause or aggravate liver depression qi stagnation. The spleen is responsible for the engenderment and transformation of qi and blood; if spleen vacuity precipitates blood vacuity, insufficient blood will not properly moisten and harmonize the liver. Spleen vacuity is, therefore, directly connected with liver depression; furthermore, since liver depression qi stagnation tends to transform into heat, spleen vacuity is frequently found in conjunction with depressive heat. Liver yang is part of the life gate fire,2 or ministerial fire, the basic fire of life (i.e. kidney yang). Therefore, depressive heat that originates in the liver causes stirring of ministerial fire below, additionally affecting the spleen, stomach, lungs, and heart above.

Blood (Yin)Vacuity

When the spleen becomes vacuous and weak, it loses its ability to engender and transform the blood, creating blood vacuity. Blood vacuity may eventually affect kidney yin because blood and essence share a common source, just as the liver and the kidneys share a common source. Liver blood—kidney yin vacuity precipitates vacuity heat. Vacuity heat originates in the lower burner or yin part of the body; therefore it is also considered a type of yin fire. This vacuity heat counterflows upwards and affects the liver, spleen, stomach, lungs, and heart.

Stirring of Ministerial Fire

Ministerial fire is the fire in the body that inhabits the life gate (ming men), liver, gall bladder, and triple heater, and it is thought to originate from and be inseparable from kidney yang. Ministerial fire is the complementary opposite to the sovereign fire, or fire of the heart. Stirring of ministerial fire is due to overactivity and overstimulation, as well as to excessive sexual activity. It is a condition in which the ministerial fire below becomes hyperactive and agitated, and it flames upwards (Wiseman & Feng 1998), harassing and damaging the viscera and bowels above it.

‘The lower burner refers to the part of the triple burner that includes the kidney, bladder, large intestine, and small intestine, in their function of drawing fluids to be discharged in the form of urine (Wiseman & Feng 1998). The triple burner is one of the six bowels comprising the upper, middle, and lower burners; it is a way of describing the combined function of different viscera and bowels by grouping them and dividing the body into three sections. It is referred to as the `waterways’, meaning that the main functions of the triple burner are the processing of fluids by the transformation of qi and ensuring free flow through the waterways (Wiseman & Feng 1988). 2The life gate is a ‘physiological entity of disputed morphological identity’ (Wiseman & Feng 1998). Some consider the life gate to be the space between the kidneys; others consider it to be contained in both kidneys. The life gate is referred to as the root of original qi and the house of fire and water, the stirring qi between the kidneys, the fire of the true yang for the whole body.

Yin fire is an invaluable theory for understanding the evolution of depression patterns and is the most common complex pattern combinations encountered in depressed patients. It is extremely common to encounter spleen vacuity, dampness, and phlegm accumulation, concomitant with liver depression transforming into heat. On the one hand the phlegm and dampness cause psychomotor retardation symptoms, lack of interest, apathy, and lethargy; on the other, the heat from qi stagnation causes agitation, anxiety, and in most cases insomnia. Recall that following the classical classification of psychiatric disorders according to Chinese Medicine (CM), depression falls within the withdrawal category; withdrawal is precipitated by either qi and/or yang vacuity, or by the yang qi not flowing freely due to liver depression and phlegm obstruction. Nevertheless, major depressive episodes are rarely, if ever, devoid of some degree of agitation and heat.

In our experience, having evaluated dozens of clients presenting with clinical depression, major depressive episodes are most often characterized by a combination of spleen—kidney dual vacuity, dampness and phlegm accumulation, and depressive heat from liver qi stagnation. The degree of severity and variety of manifestations is dependent on the person’s constitution and lifestyle, as well as the etiology of the depressive episode. Of course there are a few cases of depression primarily due to vacuity, especially spleen qi—heart blood vacuity, and there are a few cases that manifest primarily with repletion signs, such as liver depression and phlegm obstruction.

Constitutional tendencies towards either yin or yang vacuity precipitate or aggravate liver depression in specific ways. On one hand, as yin and blood develop from the same source, blood vacuity can lead to yin vacuity; because yin blood is what nourishes the liver and facilitates its functions of coursing and discharge, yin vacuity may also aggravate liver depression. When yin becomes vacuous, it may lead to yang becoming effulgent, which in turn generates internal heat. On the other hand, spleen qi vacuity may eventually affect the kidney and result in spleen qi—kidney yang vacuity. It is kidney yang, the life gate fire or ministerial fire, which promotes the liver function of maintain-ing free flow; therefore, spleen qi—kidney yang vacuity is rarely seen in people experiencing depression without concomitant liver depression qi stagnation. Additionally, spleen qi—kidney yang vacuity tends to aggravate liver depression qi stagnation (Schnyer & Flaws 1998).

With the preceding as a background, we now discuss how these mechanisms precipitate the patterns seen in depression. Qi stagnation, heat transformation, spleen and kidney vacuity, and dampness and phlegm accumulation can combine to produce the complex patterns characteristic of major depressive episodes.

EVOLUTION OF PATTERNS OF DEPRESSION

The patterns encountered in people experiencing depression are generally composed of elements of both vacuity and repletion. As explained above, patterns of depression develop as a result of the interaction of four main disease mechanisms: (1) those that evolve from liver depression qi stagnation, (2) those that directly affect the heart’s function of housing the shen or spirit, (3) those that derive from vacuity of either qi—yang or blood—yin, and (4) those that derive from repletion — the accumulation of dampness and phlegm, or hyper-activity of yang. Depression patterns are complex, formed by several different ‘basic patterns’ of both vacuity and repletion.

Repletion Disease Mechanisms

Damage by the emotions in the form of emotional stress and frustration compromises the liver’s ability for coursing and discharge; liver depression qi stagnation, if severe or enduring over a prolonged period of time, may transform into heat and eventually into fire. Depressive heat counterflows upwards, agitating the heart and spirit. Liver depression may eventually lead to blood stasis, to food stagnation, or may precipitate and aggravate spleen vacuity. If the spleen is vacuous and weak, it may not be able to transform and transport fluids, thus leading to dampness accumulation and eventually to phlegm. Phlegm may be drafted upwards by counterflowing qi, misting the heart and causing confusion and disorientation. It may also become bound in the chest and affect both the heart and the lung, or it may combine with depressive heat or fire, both agitating and misting the heart.

Vacuity Disease Mechanisms

exacerbate a predisposition to spleen vacuity. If the spleen becomes vacuous and weak, it will not only become incapable of transform-ing and transporting body fluids (a function of spleen qi), but will also fail to generate sufficient blood (and qi). This may lead to heart qi and heart blood vacuity, rendering the heart unable to store the spirit. This blood vacuity may precipitate kidney yin vacuity since the essence and the blood share a common source, as do the liver and kidney. Furthermore, depressive heat and fire may further damage the blood and yin, further exacerbating yin vacuity and giving rise to a hyperactivity of yang or fire effulgence. If spleen vacuity endures over a prolonged period of time, it may eventually progress into kidney qi and yang vacuity (Fig. 4.2).

Patterns of both vacuity and repletion can affect the heart’s ability to house the shen or spirit (i.e. shen disturbance), as depicted in Figure 4.3. Specifically, repletion patterns that affect the shen may develop from either liver depression qi stagnation or dampness and phlegm accumulation (due to spleen vacuity). Those that develop from liver depression include stagnation of heart and lung qi, depressive heat affecting the heart, and heart fire. Patterns that stem from dampness and phlegm accumulation include phlegm obstruction and stagnation, phlegm confounding the orifices of the heart, and phlegm fire harassing the heart. In turn, vacuity patterns affecting the shen generally derive from spleen qi—kidney yang vacuity or from liver blood—kidney yin vacuity. Heart blood and heart qi vacuity stem from spleen qi—kidney yang vacuity. Heart yin vacuity and vacuity heat generally stem from liver blood—kidney yin vacuity.

Again, depending on predisposing factors and the constellation of signs and symptoms, the nature of the depressive episode will vary greatly among individuals. It is still to be determined by further research, but the theory would predict that chronic or recurrent depressions, dysthymia, and nonspecified depressive disorder are characterized by significant and long-standing phlegm obstruction and blood stasis and/or by extreme insufficiency of qi and blood, or both.

DEPRESSION AND THE LIFE CYCLE

According to Chinese Medicine, the disease mechanisms that are set into motion during depressive episodes are determined in part by the stage of the life cycle in which we find ourselves. The tendency to develop liver depression may be exacerbated by one’s age or occupation; the constitutional tendency towards vacuity or repletion patterns may be influenced by diet and lifestyle choices. The following discus-sion represents an extension of the framework that we have used to date in our research studies. Thus, while the following section may be regarded as an untested extension of our approach, these addendums derive directly from eight principles theory and therefore should be consistent with our current approach. These extensions of our framework involve how depression appears in adolescence, how depression develops in women in relationship to pregnancy and menopause, and how aging may affect the predisposition to depression. This augmented framework can be used as the basis for the development of a treatment protocol for these populations. We have developed such a protocol for research in depression during pregnancy, and hope to develop similar protocols for use with the other populations in the future. In addition, we will cover in this section an aspect of depression and the life cycle that is a part of the current approach we use in our research: namely, how depression in women relates to the menstrual cycle.

Depression in Adolescence

According to Chinese Medicine, the rapid and dramatic changes that characterize adolescence make it a particularly vulnerable time for the development of disease mechanisms related to depressive episodes. Sexual development is a function of exuberance of the life gate fire or ministerial fire (the ming men or yang of the kidney), which implies a relative repletion of yang qi. This exuberance of yang necessary for growth and development acts as a natural fuel which quickly transforms any accumulation into heat or fire. The stirring up of ministerial fire agitates the liver, stomach, spleen, heart, and lungs. In addition, common frustrations characteristic of adolescence render the liver incapable of maintaining the smooth flow of qi. As mentioned above, liver repletion weakens the spleen’s ability to generate qi and blood, and to transform dampness; this weakness is frequently exacerbated by indulging in a poor diet, and by abusing drugs or alcohol.

Depression in a Woman’s Life

Depression is twice as common in women as in men (Kessler et al 1994); this fact can be explained, in part, by the Chinese Medicine view of the relationship between liver depression and the menstrual cycle. This is not to say that the higher incidence of depression in women is merely due to hormonal imbalances. Depression is the result of complex interactions between diverse factors, many of which are not yet fully understood; some of these factors can be explained bio-logically, many others cannot.

Because our research protocol excluded women during pregnancy, and did not aim at addressing specifically postpartum depression, we will first review the mechanism of depression in relationship to menstruation and menopause. In subsequent sections, we will review considerations for treating depression in conditions that extend beyond our research protocol, including depression during pregnancy and postpartum depression.

The Menstrual Cycle

According to Chinese Medicine, the heart, spleen, and kidney play important roles in the creation of blood. The spleen transforms food and liquids into nourishment, and sends the finest essence of food extracted through the process of digestion up for the heart to trans-form it into blood, while the kidney also sends some essence to the heart. It is said in Chinese Medicine that it is in the heart that the blood becomes red and is finally created (Schnyer & Flaws 1998).

Insufficient creation of blood may be due to: (1) an inability of the spleen to extract the finest essence of food and send it to the heart, (2) a lack of sufficient essence coming from the kidney, or (3) the inability of the heart to complete the creation of blood and its distribution to the whole body. It is only after the blood has nourished and moistened the viscera and bowels, the channels and vessels, and the rest of the tissues of the body, that the remaining surplus accumulates in the uterus to be discharged as menstrual blood. In addition, three viscera control the movement and distribution of blood: the heart, the liver, and the spleen. Specifically, what moves the blood is the heart qi, which in turn originates primarily from the qi of the spleen. In addition, the spleen also restrains and controls the blood within its path-ways, while the liver qi stores the blood by regulating the amount of blood in circulation at any given time. The flow and rhythm of the menstrual cycle depend upon the heart and spleen to provide the motivating force or qi for the blood to move, and upon the liver’s ability to maintain the free and uninterrupted movement of qi, and therefore, blood. For menstruation to take place, there must be sufficient blood, and the qi and blood must be able to move freely and without interruption (Schnyer & Flaws 1998).

The Phases of the Menstrual Cycle According to Chinese Medicine

A predisposition to depression and the prevalence of some depressive symptoms may vary according to the phases of the menstrual cycle. Chinese Medicine divides the menstrual cycle into four phases.

End of Menstruation

At the end of menstruation, the body is left relatively empty of blood, a yin substance. If there is an underlying vacuity of yin, the body may have difficulty in replenishing the blood that has been lost. Symptoms due to blood or yin vacuity may become exacerbated at this time. In addition, the yin may become unable to restrain yang, and heat and fire may flare upward and agitate the spirit. The focus of the treatment strategy should emphasize replenishing and nourishing the yin and blood and, if necessary, clear heat and drain fire.

Ovulation

The time around ovulation is characterized by the transformation of yin into yang. It is necessary to have sufficient yin to transform into yang, and to have enough yang for this transformation to take place. If the body has not been able to replenish the yin and blood during the previous phase, or if the qi and blood are not flowing freely, this trans-formation will also be impeded. On the other hand, if yin has been replenished successfully during phase one, the growth of yang may exacerbate underlying heat or fire, or add heat to liver depression, transforming qi stagnation into depressive heat. This yang heat may flare upwards and agitate the spirit. The focus of the intervention should be to facilitate the movement of qi and blood, and to clear heat or drain fire.

Premenstruum

Premenstrually, the qi must flow freely and in the right direction, and the yang must stay strong for a sufficient length of time. Because the qi and blood continue to focus and accumulate inward and down-ward towards the uterus, the body is usually at its hottest, because qi is yang and yang is hot. If the qi and blood are not flowing freely due to liver depression, or if qi accumulation transforms into heat or fire and flares upwards, or if the yang is not strong enough to move the qi and blood downwards, depressive symptoms tend to exacerbate pre-menstrually. Additionally, the liver’s function of coursing and dis-charge depends on the nourishment of the liver by the blood; in a woman with blood vacuity, what little blood she has will tend to accumulate in her uterus, and leave the rest of her body more empty. This may exacerbate liver depression on the one hand, and heart blood and yin vacuity on the other, aggravating the corresponding symptoms of depression. As above, the treatment of depression should emphasize coursing the liver, rectifying the qi, and clearing heat.

Menstruation

During the menstrual period itself, with the discharge of blood and the release of qi that goes along with it, there is generally a reduction in the signs and symptoms of depression associated with liver depression qi stagnation. Treatment principles should focus on supporting this movement of qi and the discharge of blood. Although theoretically, in both phases three and four, symptoms may be exacerbated by insufficiency of qi and yang, in treating depression one should focus on coursing the liver, rectifying qi, and clearing heat from the time of ovulation until the onset of the menstrual period.

In our protocol, we divide the treatment of depression in women during their menstruating years into two general phases. In the first half of the cycle, from the end of menstruation to before ovulation, we emphasize addressing the repletion components of the pattern by rectifying qi, clearing heat, draining fire, and eliminating dampness or transforming phlegm, as necessary. In the second half of the cycle, from ovulation through the onset of menstruation, we focus on addressing primarily the vacuity components of the complex pattern, by boosting qi, nourishing blood, enriching yin and fortifying the spleen, kidney (and lung), as necessary. During menstruation itself, we balance out our strategy, depending on the presentation.

Depression and Menopause

According to Chinese Medicine, blood is considered to be the outward manifestation of essence. As explained above, essence can be inherited or acquired. Inherited essence is used up through the process of living and cannot be supplemented. Acquired essence is the surplus of qi (energy) and blood (nourishment) that is produced for daily functioning through the process of digestion, performed by the spleen. With age, digestion becomes less efficient and a woman’s body no longer produces a surplus of blood to maintain a monthly period without this loss of blood becoming draining. In a sense, by using more qi and blood that can be produced effectively through digestion, one begins to ‘borrow’ from the original reservoir — the inherited essence that is stored in the kidney. Therefore, according to Chinese Medicine, menopause is viewed as a homeostatic mechanism that, in fact, slows down the process of aging. Menopause is characterized by a cessation of menstruation precisely because its purpose is to preserve the essence (Wolfe 1998).

The uterus (bao gong) is considered an extraordinary organ, connected to the kidney via the bao luo, and to the heart via bao mai (uterine network vessels). ‘The uterine vessels home to the heart and net to the uterus’ (Wiseman & Feng 1998, p. 643). The uterus is related to the kidney essence, the chong and ren channels, and the heart, liver, and spleen. During menstruating years, the heart sends blood down to collect in the uterus via the bao mai; gradually, as menopause approaches, the heart stops doing this, and menstruation becomes irregular. This illustrates one of the mechanisms through which the heart and kidney are intimately related, and emphasizes the connection between the spirit and the essence, the psyche and the soma, the body and the mind. When menstruation finally stops and the heart no longer sends blood downward to the uterus, the flow in the bao mai reverses itself, and the essence is sent up to the heart to nourish the woman’s spirit. As Flaws (1992) summarizes in his book My Sister the Moon, ‘instead of preparing the uterus for the growth of a physical addition to the community of humankind, the blood focuses on the heart to nourish the woman’s spirit’.

The factors that contribute to an increased predisposition to experiencing depression during a transition into menopause depend on the ability of the liver to maintain the free flow of qi, on the capacity of the spleen to generate sufficient qi and blood, and on the condition of the kidney essence.

Depression during Pregnancy

The disease mechanisms that can determine a woman’s risk for depression during pregnancy develop in basically the same way as they do for depressive episodes in general; therefore, they can be explained by evaluating the vacuity and repletion elements of the four features mentioned above.

The process of pregnancy per se places specific demands upon the viscera and bowels that can affect the free and smooth flow of qi throughout the body, the engenderment and transformation of qi and blood, and the movement and transformation of body fluids. The viscera most affected include the liver, the kidney, and the spleen. These factors may potentially increase a woman’s predisposition to experience a depressive episode during pregnancy.

During the first trimester of pregnancy, when menstruation ceases, blood and qi back up in the liver; the liver becomes replete and loses its ability for coursing and discharging, which creates or exacerbates a predisposition to liver qi stagnation. In addition, the liver stores the blood and it is closely related to chong mai, the ‘sea of blood’, one of the eight extraordinary vessels. Among other functions, this channel sends blood down to the uterus and it continues to do so after conception. As the fetus cannot yet make full use of all the blood accumulating in the uterus, it blocks the uterine gate, further aggravating liver qi stagnation (Flaws 1992). As explained above, if prolonged, liver depression may transform into heat or fire, and it can precipitate or aggravate blood stasis.

Throughout pregnancy there is an increased demand for qi and blood to nourish and promote the development of the fetus; this may weaken the spleen by placing an increased demand on its functions, which may result in insufficiency of qi and blood, or cause dampness to accumulate, thus leading to phlegm (Flaws 1992).

After conception it is the kidney that nourishes the fetus with essence. Blood and essence share a common source; because the kidney is also the source of yin, when so much blood and essence are focused on nourishing the fetus, the rest of the body may suffer an insufficiency of yin. This vacuity of yin may lead to yang becoming replete, and yang repletion may counterflow upwards, causing agitation and restlessness. If the yin of the kidney is insufficient, it may be unable both to nourish the fetus and to moisten and relax the liver.

The heart in turn depends on sufficient blood to perform properly its function of housing the spirit, maintaining awareness, and integrating our being. An insufficiency of blood due to spleen qi vacuity may in turn precipitate or aggravate a disturbance of shen due to heart blood vacuity.

Postpartum Depression

The process of labor and delivery, in conjunction with specific features of the postpartum period, may lead to disease mechanisms that can precipitate depression. According to Chinese Medicine there are two main disease mechanisms that characterize the onset of depression during the postpartum period. Vacuity patterns may develop from excessive blood loss (and fluid loss through profuse perspiration) and excessive use of qi through exertion during labor. Excessive loss of blood during delivery may leave the heart qi and blood vacuous and weak. Because the blood nourishes and secures the spirit, blood vacuity may lead the shen to become unsettled, resulting in anxiety and restlessness. A prolonged and difficult labor resulting in extreme exertion can lead to qi vacuity of both the kidney and the spleen; this gives rise to fatigue and to what is known in Chinese Medicine as lassitude of spirit (lack of mental vigor and physical strength). In addition, because the blood nourishes the liver and allows it to maintain the smooth movement of qi and blood, blood vacuity may cause or exacerbate qi stagnation (Flaws 1997).

Repletion patterns primarily result from or become exacerbated by liver depression qi stagnation. For many women, the postpartum phase is characterized by a mixture of awe and elation on the one hand, and unforeseen psychosocial stressors on the other; the natural stress of caring for a newborn child may further aggravate a predisposition to liver depression qi stagnation.

If for some reason stagnant blood is retained after delivery, or the postpartum lochia is not expelled properly, blood stasis may exacerbate qi stagnation. Blood stasis and stagnation can counterflow upwards, penetrating and disturbing the heart. In addition, heart blood and spleen qi vacuity may aggravate blood stasis. When blood loss results in heart blood vacuity, the blood vessels are not well nourished and are less capable of moving and transporting the blood. When exertion results in qi vacuity, there is less qi available to move and transport the blood (Flaws 1997).

Liver depression can result in spleen vacuity and an accumulation of dampness and phlegm. In addition, because of the hard work of labor and delivery, and the tremendous physical demand to produce enough nutritious breast milk for a newborn, postpartum women crave rich foods, which unfortunately are also very difficult to digest. If the spleen is already weak and possibly affected by liver depression counterflow, overeating rich foods may also contribute to the production of damp-ness and phlegm. Enduring or severe liver depression may transform into depressive heat. This heat may stew and congeal the water fluids, also resulting in phlegm. Phlegm may obstruct the orifices of the heart, and obscure the functions of the shen or spirit, or it may combine with depressive heat and develop into phlegm fire.

Depression and Aging

According to Chinese Medicine, aging is a decline in the production and free flow of qi and blood. Traditionally, problems related to aging have been addressed in Chinese Medicine by emphasizing supplementation of qi, blood, yang, and/or yin. However, Yan De-Xin (1995), a leading Chinese physician who has revolutionized the field of TCM geriatrics, affirms that the chief mechanism of aging is the loss of regulation and harmony of qi and blood (i.e. stagnation; De-Xin 1995).

In addition, prolonged or severe qi stagnation results in blood stasis. For these two reasons, in the elderly the vacuity disease mechanisms that characterize depression are likely to be complicated by not only qi stagnation but also by blood stasis.

Five main disease mechanisms help us to understand the progression and development of depression in the elderly:

  1. A decline of essence that depends on the kidney, and which in turn affects the kidney’s function of providing the foundation for both yin and yang
  2. A weakening of the spleen’s ability to transform food into nourishment, which affects both the production and the movement of qi and blood
  3. An aggravation of liver depression qi stagnation in turn due to qi and/or yang vacuity, and vacuity of blood and/or yin
  4. The inability of the heart to house the shen or spirit due to blood and yin vacuity
  5. A weakness of the shen itself due to qi vacuity. Decline of Essence

As explained above, the kidney stores the essence; there are two types of essence — inherited and acquired. Because inherited essence is finite, it cannot be replaced or augmented; it is spent through the process of living. The rate at which we grow older is dependent upon our constitutional endowment of this essence and upon how well we take care of it. Stress, overwork, excessive sexual activity, and drug and alcohol use all contribute to the depletion of our inherited essence.

Weakness of Spleen Function

Our acquired essence, on the other hand, is derived from food and drink, and is dependent upon the spleen’s function of transforming food into qi and blood. Acquired essence helps to enhance and support our inherited essence: if one eats well and the process of digestion is effective, and if one does not spend more qi and blood than are created each day, then during sleep the surplus of qi and blood is transformed into essence. Around the age of 35 years the spleen becomes weak and its ability to transform food into nourishment begins to decline. The reserves of inherited essence are tapped and eventually, because of the interdependence of the spleen and the kidney, the kidney also becomes weak. The production of qi and blood becomes progressively more scanty (Schnyer & Flaws 1998).

Aggravation of Liver Depression Qi Stagnation

The free movement of qi can take place effectively only if there is sufficient qi being created to propel it. Similarly, there must be enough blood to moisten and nourish the liver to maintain its function of regulating the smooth flow of qi. Symptoms of liver depression tend to increase when there is less qi or less blood available. In addition, the functions of the liver depend on the yang of the kidney, which provides the foundation for the production and movement of qi. In sum, liver depression can be aggravated by qi and yang vacuity on the one hand, and yin and blood vacuity on the other.

Inability of the Heart to House the Shen

The blood provides the material foundation for the shen or spirit; without enough blood, the heart loses its ability to house or anchor the shen. When there is a decline of blood, the shen becomes unquiet and restless; symptoms of heart blood and yin vacuity, such as insomnia, anxiety, and fidgetiness tend to increase.

Weakness of Shen

Because the shen or spirit is understood as the accumulation of qi and blood in the heart, a decline in the production of qi would make the shen weaker, less bright, and less clear.

Jean-Paul Marat

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